Obamacare – A View from the Front Line

affordable-care-actby Tia Will

As an advocate of single party payer health care administered through an integrated health care model such as Kaiser, I was not happy with the ACA. I wanted more. But that has not stopped me from realizing the benefits that I have seen directly both within my own family and for my rapidly increasing number of patients.

The ACA is a large program with a number of provisions. As with any large, complicated structure, it has some good features and some that may not work out so well. In short, I see it as a step in the right direction, not a panacea. Since this is a “front line view” I will present what I have seen as an indirect beneficiary of the plan and as a primary care doctor.

The first provision of the plan that affected my life was the extension of parental medical insurance to children until the age of 26. Immediately after graduating from UC Berkley and prior to anticipated application to medical school, my daughter, then age 22 was diagnosed with anorexia. This chronic relapsing condition has a 1/5 mortality rate. Effective treatment frequently involves multiple inpatient hospitalizations costing upwards of $ 150,000 each followed by intensive and expensive outpatient therapy. Without my insurance plan, my daughter, the new graduate, who had done everything our society expects from our youth including college, work, and volunteer activities would have had no way of accessing the potentially life saving treatment once my financial resources were exhausted.

This was what our previous “best in the world” health care “system” of fee for service medicine would have offered my daughter. It was what we previously offered many healthy young people who don’t perceive the need for health insurance until they are stricken with a major illness or accident. This provision of the ACA saved my daughter’s life while saving me from bankruptcy after 30 years in medicine. Since this dramatic event in my life, I have had many young women able to keep me as their doctor because of this provision of the ACA.

Moving beyond anecdote, the primary purpose of the ACA was to decrease the number of medically uninsured Americans thus providing improved access to medical care for those not fortunate enough to be within the most affluent economic group.

Recent polls reflect the decreasing percentages of Americans who are uninsured.

From a Gallup poll in May

“The uninsured rate for U.S. adults in April was 13.4%, down from 15.0% in March. This is the lowest monthly uninsured rate recorded since Gallup and Healthways began tracking it in January 2008, besting the previous low of 13.9% in September of that year.

There is much variability from state to state in enrollment in ACA based insurance largely dependent upon how many resources were allocated by the state to provide a framework for enrollment and whether or not the state opted to enact Medicaid expansion. Since this is a front line view, I will focus on what has occurred locally.

Although my position with Kaiser will not allow me to provide specific numbers,

I can say that within the Sacramento area ranging from Davis on the west to Folsom on the east, Kaiser’s membership growth through Covered California has outstripped our predictions by a large number. This unanticipated degree of growth carries with it one of the major concerns about the ACA which was inability of current providers to meet access demands. We will be meeting this increased demand by doing the obvious, hiring more providers. To a front line care provider, this is a win –win situation. More people able to obtain preventive services will in the long run decrease the overall cost of their care. It also creates more job opportunities for those needed to provide that care including doctors, nurse practitioners, physician assistants, physical therapists, nurses, medical assistants, and support staff. This growth of economic opportunity should have universal appeal.

Another objection to the ACA has been that those who previously had health insurance plans that they were happy with would be able to keep them. This did not turn out to be the case for a number of our patients. There was concern that we would lose membership from our limited coverage plans. What actually happened is that the majority of our patients who lost coverage in this manner re-signed up with Kaiser through Covered California with expanded coverage.

Another objection to the ACA is the mandated nature of insurance. The question I am frequently asked is “why should people have to buy something that they do not want or feel that they need?” My response is that they should not. My preference is universal health care coverage. However, due to current political realities, that is not an option at this time. What people who ask this question are overlooking is that many people do not want insurance or feel that they need it ….. until they do.

Individuals of all ages are subject to unexpected illness and accidents. Within the past month, I diagnosed breast cancer in a woman under 30. When the individual is uninsured, regardless of reason, we all end up paying for their care either through increased insurance premiums or increased taxes or both. The alternative would be to allow them to die at home or on the side of the road and even the most ardent libertarians will not admit to advocating that policy.

In my individual practice, I see many young women who do not perceive themselves as having any major medical problems and yet benefit from preventive health care services prepaid, and thus dramatically less expensive than they would be in the fee for service world. As just one example, an IUD that would cost about $800.00 dollars in the fee for service medicine world costs less than half that due to our economy of scale and model of care provision. For most of my patients, it costs them nothing more than the copay for their visit, usually under $30 dollars. I can imagine those advantages not limited to a particular insurance plan, but spread across our entire population. What opportunity for health care cost savings in the long run !

Here in Davis , the ACA has presented as a sharp increase in the number of new patients. On the level of the individual primary care doctor, I am seeing an average of 4 patients new to Kaiser daily. While this would not be unusual for an Ob/Gyn within the first few years of practice, it is virtually unheard of for a doctor with a stable practice of 22 years. Another change is that for many years, Kaiser had a far higher proportion of upper economic group patients. What we are now seeing are many more patients from the lower economic groups. These are the same folks that I was previously seeing only in the Emergency Room and for their one mandated ER follow up visit before discharging them back into the ranks of those unable to obtain routine preventive and non emergent care. What is certain is that I can provide far better and more cost effective care on line, over the phone, and in my office than I can provide in the ER.

My preliminary view from “the trenches” of primary care medicine is positive. What I see are increased opportunities for individual patients, who would otherwise do without, to access preventive and early intervention care services. This in turn has lead to increased employment opportunities within the health care field and the opportunity to provide care in the most cost effective way. The ACA is far from perfect. It continues to link health care to insurance instead of providing universal coverage. It continues to link health care to employment outside the home thus inhibiting job mobility and in some cases , social choices such as whether to join in marriage or to divorce although to a much lesser degree than with our previous system in which case either of these changes could prove catastrophic both medically and financially. Although not perfect, the ACA is, from the front line, so much better than what we previously considered “the best” that I cannot even imagine stepping back from this “small step forward” towards universal health care provision.

About The Author

Tia is a graduate of UCDMC and long time resident of Davis who raised her two now adult children here. She is a local obstetrician gynecologist with special interests in preventive medicine and public health and safety. All articles and posts written by Tia are reflective only of her own opinions and are in no way a reflection of the opinions of her partners or her employer.

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117 thoughts on “Obamacare – A View from the Front Line”

  1. D.D.

    One of my close friends has a son with a severe mental illness and a daughter living with multiple sclerosis. This has caused the entire family to also need family therapy. Both parents have worked since high school and never been on any kind of public assistance. They would have lost their home without the ACA. As it is, with co-payments, they won’t be able to retire until their 70’s, even though they saved enough to retire at a slightly lower age if their children had been healthy.
    My own family is benefitting from the ACA as well.

  2. Tia Will Post author

    D.D.

    Thanks for the stories. I feel that it is in the individual anecdotal stories that the positive effects of Obamacare will be told. As a society, we didn’t pay much attention to the individual tragedies in the form of lost employment, lost homes, bankruptcies that occurred not because anyone was shiftless or lazy, but because someone became ill.
    Unfortunately, I doubt that these stories will be heard since they tend to affect those from our lower socioeconomic groups whose voices do not speak as loudly in our money driven “free speech” media. What we do hear are the complaints from those who this will never affected since they have either the money or excellent health benefits, or both.
    Hopefully, we will be cognizant and appreciative of the lives and families saved by the availability of health care which many have lacked under our previous market driven, fee for service model.

    What I am hoping is that more and more people will share their stories thus countering the “what if” fears that seem to predominate in the anti ACA media. Personally I value the lives saved above the admittedly rocky start with the initial sign up or the messy politics of its enactment. A technical glitch or a bit of clumsy political manipulation do not even come close to the value of a person’s life in my view.

  3. Highbeam

    My new Kaiser plan certainly saves me money on the monthly premium, but having the vision care removed from all CoveredCA plans has hurt (it is out of pocket, so WalMart and Costco are the most affordable)…saving monthly dollars now does not yet help on freeing up money for getting an eye exam and new contacts, as I am still reeling from the monthly premiums I was paying for the past few years on the grandfathered plan.

  4. Topcat

    Tia, Thanks for a well thought out description of how the ACA is working out. We rarely get such a view from the politicians who are using health care as a political weapon against their opponents.

    1. Tia Will Post author

      Topcat

      Your post, in combination with the most recent Court Watch article, have brought back to my attention just how much we are losing by maintaining our adversarial model not only in our judicial system but also throughout our society. When thinking about other areas where this applies in our society think of the word competition in the place of adversarial.

      Competition certainly has a place in the overall economy. Choice is good when it comes to brand of cereal or what type of car to buy. Medicine is fundamentally different for a number of reasons.
      1) Health care is both individual and communal. On the individual level, each decision a person makes may have
      unforeseen and potentially life altering consequences.
      When a patient takes a medicine, the effect in their body can be vastly different than the effects it has on your
      neighbor. Non medical folks rarely have the in depth knowledge to decide on their own how medicines may
      interact with their individual physiology.
      2) On the communal level, one individuals decision to be immunized against pertussis may be the decision that save the life of another family’s baby. The difference between this and say buying a safer model car is that the effect of a brake failure is visible to all whereas the effect of the immunization is invisible, unrecognized, but no less critic.
      3) Not only are some of the benefits of medicine invisible, so are the costs.
      If you go out to buy a car, you know before you make the decision to purchase just how much that car will cost you. This is rarely true in medicine. Whether you are insured or uninsured it takes a lot of digging to find out the costs of procedures and medications before you actually decide to proceed, especially in the hospital setting.
      4) People like the ability to choose their own doctor, but rarely make this decision based on any rational criteria.
      We tend to choose doctors based on word of mouth, which in turn is frequently based on how well a friend or family member liked a particular doctor, not on the competency of that doctor. So imagine if as doctors, we felt absolutely free, with no fear of a decline in income to tell a prospective patient. I am happy to take care of you within my area of special knowledge, but I think you will be much better off if my colleague, Dr. X takes care of you for your particular condition since he is much better with that than I am. This is exactly what we currently do within Kaiser.
      Now, imagine how much better care we would be able to provide if instead of UCD, Sutter, Mercy and Kaiser ( in our area) were collaborating on how to provide the best care possible to all people in the region instead of constantly fighting each other ( and spending money on advertising). I can envision a regional health care system in which each system concentrated on providing the best possible care in given areas of excellence , for example, Roseville Kaiser could be designated the regional center of excellence for Maternal Child care, UCD were the designated center for trauma care, Sutter the center of excellence for cardiac care ….

      Instead of pitting doctors groups and hospitals against each other the way traditional fee for service medicine has
      worked ( or rather not worked for years) we could be spending our time and energy perfecting our practice, taking advantage of economies of scale and providing truly integrated services between systems. Kaiser has set the bar for this kind of collaborative practice in our region and others, to their credit are developing their own similar processeses. I get paid no more or no less if I order a test, consult with a specialist, perform a surgery, or avoid that surgery by taking care of the problem conservatively before surgery is needed. I can envision the power of this same kind of integration of services throughout our region, not only within Kaiser.

      What it would cost us however, is our short sighted and ideologically driven idea that the free market is the best process for all aspects of our society.

      1. Topcat

        One aspect of this whole discussion is that a large proportion of overall health care spending does not actually go to providing healthcare, but rather to insurance companies, excessive administrative costs, bloated bureaucratic costs, and just pure waste and corruption. Estimates I’ve seen are that 1/3 of healthcare spending does not go to providing healthcare.

        It seems like there must be a better solution to providing healthcare in this country than the extremely inefficient patchwork system we have now. Imagine how much healthcare we could provide if we could just eliminate some of the overhead cost.

        I do wish that the critics of the ACA would come up with a good, workable solution that would have a realistic possibility of being implemented given the political and financial realities we face.

        1. Frankly

          The critics of Obamacare have come forward with plenty of good workable solutions that would have easily increase access to 3.5 million people at a much lower price tag.

          And I agree with your point about all the money going to business between the doctor and patient. The reason we have so much business between the doctor and the patient is because of three things:

          1) The doctor previously did a lousy job working to control costs. And the hyperinflationary cost of healthcare was temporarily slowed by the rise of the HMO.

          2) Government regulation of healthcare has exploded to saddle health care providers with much higher administrative costs.

          3) Trial lawyers have raped and raided the system with legal extortion and frivolity.

          The solution is to essentially unravel the problems from #2 and #3 above, to regulate and incentivize doctors to do much better with #1, and to get more people working for a living so they can purchase their own health care services.

          And related to his final point, to honestly assess the costs and impacts of our out of control immigration that is putting so much pressure on American services like healthcare and education. If we consider the full extent of illegal immigration to this country over the last 30 years, that number equals the majority of the 50 million people claimed to be without insurance.

          We pay for our out of control immigration in many ways… basically paying an increasing tax burden to provide Democrats with voters to keep them in power, and business cheap labor to keep the owners wealthy.

          So, one of the solutions to our skyrocketing healthcare costs is to be honest about illegal immigration and amnesty and demand that those demanding we allow one or both to come up with the money to support them.

        2. DavisBurns

          I agree. I don’t want to pay for insurance agents and/or their companies nor do I want to pay for advertising. I have one problem with Kaiser; they limit their liability to $250,000. If there is a serious mistake made providing medical care, this limit on damages is ridiculous. Yes, malpractice suits can be frivilious but what about when someone dies or is seriously injured from the medical care they receive?

          1. Tia Will Post author

            DavisBurns

            Perhaps I am not understanding your concern about liability,or perhaps you are not understanding the Kaiser policy.

            As I understand this, Kaiser pays for all of the care necessary for an individual who has an adverse outcome in one of our facilities. There is a limitation on compensation for “pain and suffering” so that may be what you are referencing. However, Kaiser, just like any other agency can be sued. While this goes through arbitration rather than to a jury, the amounts settled upon can certainly exceed $250,000. This I know from years of attending med-legal conferences and seeing the outcomes including payouts.

          2. DavisBurns

            Tia, in choosing a policy for adult children, I found the info in the application. This was Med-I Cal so maybe they are special. Maybe they are poor and therefore have a limited need for compensation.

  5. Tia Will Post author

    Highbeam

    Agree on the vision plan. I was surprised when I received a higher bill for my most recent pair of contacts. So at least in the case of Kaiser, it is not just the ACA eligible who were affected by the change in vision care services.

  6. Michael Suhany RHU REBC ChHC

    The Affordable Care Act has certainly helped a large segment of the population obtain or keep quality, affordable health coverage. It is certainly generous to state that the ACA also has features “that may not work out so well.” Whatever flaws that exist in the legislation, however, the answer is most certainly not to move to a single payer system.

    It is true that “fee for service” is a broken system, but fixing that broken system with Accountable Care Organizations more likely requires the presence of the insurers as an essential part in managing the care and administering the claims than not.

    In my state with a Federally Facilitated Marketplace that chose not to expand Medicaid, those between 100% and 133% of Federal Poverty Level were enrolled in Marketplace plans with an Advanced Premium Tax Credit and Cost-Sharing Subsidies and were far better off than had they been forced into the Medicaid system.

    I am not sure what the objection to the mandated nature of insurance could be if the suggested alternative is essentially mandated single payer coverage and the mandated tax increases that would accompany it.

    Even better than a system that would pay providers the same if the recommended treatment resulted in lower claims expense is a system that would pay providers more in exchange for better outcomes. That is why you see insurers partnering with providers in the development of ACOs.

    And the choice of one’s medical providers is always best left in the hands of the individual as much as possible.

    1. Tia Will Post author

      Michael Suhany

      Thank you so much for your thoughtful reply and insights.

      “Even better than a system that would pay providers the same if the recommended treatment resulted in lower claims expense is a system that would pay providers more in exchange for better outcomes”

      I agree with the desirability of payments for better outcomes. Kaiser is working steadily on incentives for improved outcomes in our very large group practice. I do not see these two goals of better outcomes and lower claims expense as mutually exclusive but as goals which can both be pursued.

  7. Frankly

    Competition certainly has a place in the overall economy. Choice is good when it comes to brand of cereal or what type of car to buy. Medicine is fundamentally different

    Medicine is different, but there it still would be better served with competition. There are a lot of unique industries that deliver unique products and services that are plenty well-served by regulated free markets and competition. The Kaiser model exists because of regulated free markets and competition. Without regulated free markets and competition the Kaiser model would never have evolved because as a government-run enterprise there are not enough motivations and incentives to innovate. Look at the USPS… that is the model for what all government-run business will become and it significantly sub-optimized relative to the regulated free market alternative.

    Over the next decade, the Congressional Budget Office (CBO) estimates Obamacare will cost American taxpayers $1.798 trillion. The Republican Senate Budget Committee says CBO’s numbers rely on overly optimistic economic assumptions and puts the true cost at $2.6 trillion.

    Along with all of the lies told to sell this terrible legislation to the public so Nancy Pelosi could read what was inside it, and all the exceptions for politicians and the union friends of the Democrat party that rammed it down the throats of a majority that still today does not want it and does not like it, and then all the required multiple unlawful executive orders to get it to function and delay it so it did not damage the economy even more than it already has, we get about 3.5 million new people on health insurance out of the claimed 50 million uninsured at a cost of $1.8 to $2.6 trillion over 10 years.

    Now, this might be considered a “good deal” by the social justice obsessed, but the problem is and always has been “WE CANNOT AFFORD IT!”

    And because we “CANNOT AFFORD IT”, we should have taken a different approach. We should have taken the approach of insurance industry regulation and reform, free markets, competition and a growing economy so that more people could earn enough money to buy health insurance.

    But here is what is missing from the CBO numbers… the impact to the economy. First the business uncertainty that kept investment capital from flowing to business growth. This then causing dismal job growth. Along with saddling young people with trillions in additional debt, Obamacare shot them with a big delay in their career development… something that will cause them to have significantly lower earnings over their lifetime and crippling their chance to reach anything close to the economic success of their parents.

    We got this wrong… very wrong. And the positive point that 3.5 million new people have health insurance falls way short of making up for all the damage caused and all the damage that will be caused.

    Obamacare will be the Albatross around the neck of the Democrats for as long as the media and universities are unable to develop enough of a propaganda engine to blame it on everyone else. And given their recent track record and behavior, I expect they are already working on that.

      1. Tia Will Post author

        TBD

        The choice to convert a position from full time to part time, or to provide a patch work of part timers each with completely erratic hours lies with the individual employer. This is not the fault of President Obama. Different employers choose to handle the schedules of part time employees differently. Some show no respect whatsoever for the schedule or outside responsibilities of the employee. Some bend over backwards to help their employees achieve a schedule that is compatible with their outside responsibilities and goals. President Obama is not in any way responsible for the caring attitude of some employees nor should he be held accountable for the callousness of others.

        1. Don Shor

          The employer mandate is that employers must cover full-time employees if they have 50 or more workers. They don’t have to cover part-time employees. If they have 100+ employees, the mandate begins in 2015. If they have 50 – 99, it begins in 2016.
          So, the Republicans put forth a proposal this spring that would re-define the workweek at 40 hours. Anyone below 40 hours would be part time. Whatever they set it at, some employers will reduce hours below that level to avoid having to pay health insurance.
          So what would happen if they raise the definition of “fulltime” back to a 40 hour workweek?

          The CBO estimated that Young’s bill would lead to 1 million people losing their employer-based insurance coverage in the 10-year period ending in 2024.

          The Heritage Foundation assumes that many of those workers would, having lost their employer-based coverage, move to Medicaid. Both CBO and Heritage assume that such a move would increase the deficit.
          So it’s a little hard to take Republicans seriously about reforming or improving the ACA. When I hear “repeal and replace” I doubt they’d get past “repeal.” I know the Tea Party base is dead set against “replace.”
          There are any number of ways this 30/40 hour problem could be adjusted and coverage could be expanded, if that was the goal. If they wanted to minimize the impact of employers reducing hours, they could, of course, include a mandate that part-time employees be covered. But anything that expands coverage appears to be anathema.

          1. D.D.

            Re: unscrupulous employers manipulating their payroll: I saw this in the workers comp industry. The rates were based on 100 dollars of payroll, so of course some of the workers were paid under the table. Hopefully, these employers never suffer a catastrophic event where 10 workers need help but only 8 are officially on the payroll. Oh, wait, then the uninsured funds kick in and we all pay until fraud is proven.

  8. Tia Will Post author

    Frankly

    “Without regulated free markets and competition the Kaiser model would never have evolved ”

    While it may be true that without free markets Kaiser would not have evolved ( we don’t know that because of course we do not know what “would have happened” had any particular different path been chosen) that does not mean that we should just accept the Kaiser model as the product of the free market and thus a declaration that this means that the free market is the best possible system. I believe that we should be constantly re evaluating all of our systems to see whether or not we can do better.

    As to your comment “we cannot afford it” it depends on what you value most highly, human lives, or if you only want to consider “material harm” as meaning money. I cannot help but notice that you have never responded directly to my comments about my daughter’s individual plight as it would have been under fee for service and how it worked out under Obamacare. In my daughters support group were at least 5 women whose survival was literally dependent on the enactment of Obamacare. There were young women who had aged out of their parents plans at 22, and were surviving from one ER stabilization to the next, hoping to make it until the first provisions of Obamacare went into effect so that they could get effective therapy rather than just an electrolyte “patch” which was all that was available to them in the ER.

    When you are able to explain to me how we can “afford” to have one in five of these very bright, ambitious young women die because of their inability to “afford” effective treatment, then I might be able to understand your position a little more clearly. In my opinion, if we can afford subsidies to farmers, supporting our “friends” oversees such as Israel, military ventures abroad, establishing and manning a border fence, then we can certainly
    “afford” to keep our own children from dying.

    1. Frankly

      When you are able to explain to me how we can “afford” to have one in five of these very bright, ambitious young women die because of their inability to “afford” effective treatment, then I might be able to understand your position a little more clearly.

      With all due respect Tia (and I have a lot of it for you) I don’t think you are very good at listening to me, or else you have some tone deafness to what I have been saying.

      First point, you know me and you know that I am never in favor of our children being harmed. Now I might draw the line a bit younger than you in definition of “child”, but suffice it to say that I think you and I would be in synch for the most part in our concern about our children.

      The concern is not materially different, it is the methods that are entirely different.

      And please forgive me as I try to diagnose that difference and risk your ire for me telling you how you think (been there, done that).

      I think much of our difference boils down to our views of money within our social system. You appear to barely tolerate it as a necessary evil having negative consequences that must be overcome with legislated outcomes, engineered fairness and government redistribution. I view is as a necessary necessity because it results in the most fair allocation and most efficient natural use and allocation of scarce resources.

      You have previously put forth some nebulous ideas for setting wages based on level of effort… conveniently leaving off the complexities of design for something so profound, and the pros and cons of using this to replace market value. Let’s start with one of the clear “cons” we can see today. Government has decided that they must pay equal to what other peer government employees pay. And then we hear things like teachers and firefighters are hard-working deserving heroes all that pay and more pay… basically justifying their wage levels using your “level of effort” idea. How is that working?

      The bottom line problem with your desires and demands to replace regulated free markets with social engineering and legislated fairness is that someone has to decide what is fair. And when someone can decide what is fair, that someone is corruptible, and the power attracts bad actors seeking to leverage the power for their own benefit. Again, this is what we see with respect to government worker compensation. That is the model you would wrought on the world should you get your way. That is the model of a collectivist and everywhere we look historically and currently, those empires have failed, and those countries are failing. The people are more miserable, and their leaders more corrupt. And this then leads to other problems like passenger jets being shot down by missiles because the leaders have to create political diversions to keep their people from revolting over their misery.

      As long as we are primarily a market based society where money must be earned to purchase goods and services that are needed and wanted, there is no escaping the need to go earn enough money to acquire those needs and wants.

      I am willing to give up hyper concern over the environment, and also give up my desire to not have my city or neighborhood change, so that there are more business, more economic activity, more jobs… basically more opportunity for people to earn their own money to purchase their needs and wants.

      My guess is that the schools your daughter attended did a crappy job with this. They did not prepare her well enough to go out and acquire economic self sufficiency. They instead indoctrinated her into thinking that making money is the root of evil and that she should go out and save the world while foraging and living on sunlight and batteries. But then there comes some illness and she does not have the money to pay for needed healthcare services.

      And her government did not help either. Her government does just about everything wrong with respect to growing opportunities for her to make enough money to pay for her own way.

      Listen, I am okay with society subsidizing some of the social cause workers. We cannot afford to have too many of them, but certainly there are jobs that have social value beyond what the market will ever pay because the value created by the jobs generally has no market value and all social value. But for the jobs that have market value, the market should rule and government should get out the way.

      My views on healthcare is that we screwed up and are screwing up not making it UPS or FedEx. And instead we are making it USPS. We are going at it the complete wrong way because we have people in this country that don’t understand or don’t care because their politics are more important that are optimum solutions.

      That sucks… pardon my French.

      1. D.D.

        Frankly, often you make intelligent arguments but I’d listen more if you didn’t immediately start your arguments with comments that make me feel like you are trying to convince readers that the person who disagrees with you has some kind of personal defect.
        And by telling you this, I’ve fallen into the same pit that I ask you not to fall into.
        Just make your point, and try not to put down the other person, or their family members, while you are doing it.
        I promise I’ll try harder to do the same, too.

        1. Frankly

          D.D. those are useful words. However, I don’t like repeating myself over and over having points ignored. It shows that a person is not listening.

          Maybe we can all practice paraphrasing and echoing as a way to force ourselves to listen.

      2. Tia Will Post author

        Frankly

        “My guess is that the schools your daughter attended did a crappy job with this. They did not prepare her well enough to go out and acquire economic self sufficiency. They instead indoctrinated her into thinking that making money is the root of evil and that she should go out and save the world while foraging and living on sunlight and batteries. But then there comes some illness and she does not have the money to pay for needed healthcare services.”

        OK, you are right. Now you have managed to raise my ire.

        Apparently you have not been listening to me at all about my daughters situation. She was not failed by the schools. She was thoroughly prepared. She had done very well throughout grade school, high school and in Berkeley. She had a high score on the MCAT and fully intended to apply to medical school.

        At no point did any of these institutions fail her, nor did she fail to appreciate what it would take at any step along the way to achieve her goals. While she was scoring at or near the top of her class consistently, she rowed crew, engaged in volunteer activities both locally and abroad, and worked as a swim instructor during her high schools summers when she was not abroad.

        What failed my daughter was her health. When she was admitted to an inpatient facility for the first time she weighted 74 lbs ! If this had happened just one year earlier, it would not have been our educational system, or the teachings of her liberal mother that failed her. It would have been our fee for service medical system that you repeatedly and erroneously claim to be the “best in the world that would have failed her.

        Despite your assumptions about what the daughter of a liberal like myself must believe, let me tell you what has actually happened. My daughters condition has stabilized especially over the past year. She has volunteered during that time but was not physically up to the rigors of a regular paying job. She has been steadily working towards that goal however.
        She recently got her first paying job as a regional supervisor for a reading program. Her comment to me …… I am sorry it is taking me so long to get back on my feet”.

        “And her government did not help either”

        Dead wrong again Frankly. Our government is what allowed me to become a doctor. First by providing Social Security which supported my mother, sister and myself until I became able to work. Our government provided me with my first “on the clock” job, a summer work program for disadvantaged youth. The government then helped me again through the provision of low cost college and university experiences. It again helped when I received scholarships, grants and eventually the opportunity to study in return for service as a
        General Medical Officer. Finally, Obamacare provided the insurance change that covered her hospitalizations and interim care which kept her alive.
        Please, please do not tell me that the government has not helped my daughter or me.

        So the next time you decide to make highly personal comments about how my daughter has been failed….why not ask me what has actually happened first ?

        1. Don Shor

          But then there comes some illness and she does not have the money to pay for needed healthcare services.

          I seriously wonder if Frankly has ever had a significant medical procedure done and seen the actual bill for it. When my son broke his ankle in three places, the bill came to $17,000. With our 80/20 plan at the time, our share of it was $3400. That was fifteen years ago. Multiply in double-digit inflation of health care costs over the last decade plus to get today’s dollars. And we didn’t exactly shop around as to what hospital to rush him to, or ask at intake what the fees were going to be. In fact, in all of the cases where my kids needed emergency services, I had to sign an agreement to pay as they were discharged — without any clue as to what amount I was agreeing I would pay.
          Medical care out of pocket would bankrupt most people. Medical care with inadequate insurance — a very common phenomenon for those who have to buy insurance on the individual market — could bankrupt people. It was, in fact, bankrupting people. And insurance plans were getting more and more restrictive and insurers were dropping people in increasing numbers.

          1. Frankly

            Not only is the answer yes, but add to my family problem chronic health issues that require a lifetime of medicine. I have a high deductible plan and max out the deductible every year.

            Guess what? Good healthcare costs money. Got go out and make it. Got give up other things in life if you need money to pay for family healthcare.

            Hyper-inflationary costs are the primary problem next to the problem of pre-existing conditions. I am not paying too much for my insurance, my insurance is paying too much for the healthcare services. I don’t like paying so much, and I absolutely hate the difficulty I have shopping for alternatives on price, because nobody will tell you what the damn procedures will cost out of pocket.

            The entire system is ripe for free market reforms.

          2. Don Shor

            Overall, health care demand is (if I recall my econ correctly) price inelastic. Unfortunately, demand for preventative health care is relatively elastic. The ACA has done insurers a huge favor by virtually eliminating elasticity as a factor in demand for health insurance. So now the industry, receiving this huge windfall, has an obligation to provide insurance that meets a minimum threshold of basic care and that provides key preventative services that people would otherwise forego.
            You as a consumer have almost no way of making an informed decision about the health care you purchase. The ACA has made purchasing health insurance considerably easier and you have, at least, the potential to be a more informed consumer of insurance (it’s much easier to comparison shop, thanks to the exchanges).
            Overall, none of these conditions, along with some areas where there is limited choice of insurers and health care providers, lend support to your notion that health care is ripe for “free market reforms.” Certainly the health insurance and health care and pharmaceutical industries have little reason to support those reforms, as they have done very well under the previous and current systems.
            The best we can hope for is that government regulation will prevent the worst abuses that were occurring at increasing levels before, that coverage will expand which can help reduce costs overall, and that single-payer systems such as Medicaid will deal with the lowest-income folks.
            There are still millions of poor people without coverage because some governors refuse to accept the Medicaid expansion, so some form of single-payer expansion is going to be necessary to circumvent that.
            Other than that, the ACA is here to stay and will provide a reasonable expansion of coverage. It was challenged in a presidential election and the challenger lost. It was challenged in court, and the court upheld it. Any changes will be revisions, not repeal, not replacement. Any free market reforms would almost certainly be strongly opposed by the industries that are providing insurance and care. Any move to single-payer will only be through existing systems. This is what we’ve got, and it’s time to stop fighting it and seek to improve it in ways that expand coverage and help to reduce costs.

          3. Frankly

            Of course you have the ability to make and informed decision about the quality and cost of care. There is tremendous variability in those things, and so inelasticity of demand isn’t the issue. There is inelasticity of demand for housing… we all need it, yet there is a lot of variability. Kaiser is a unique service model that is different than Sutter. There is another example of variability.

            When my mother had brain cancer and we were referred to what we were told was one of the top oncologists in the state, there were so many problems we had to fire her. The diagnosis of that problem what that she, the doctor, was used to her patients’ incapacity to advocate for their own care and would give themselves completely to her… and she derived her job satisfaction from this feeling of being the only qualified decision-maker.

            If by inelasticity of demand you mean that people cannot advocate fort themselves and shop for the best care value, then I completely disagree. In a lot of respects it is no different than finding a mechanic to fix a problem with your car.

            People without coverage, people without coverage. We have Obamacare and yet you are still complaining about people without coverage.

            Why do we have people without coverage?

            In your view it is because we don’t take more from those that have/do, and give more to those that can’t/don’t.

            Listen, I would be pissed not being able to get coverage because of pre-existing conditions. I would be doing anything and everything to be working for a company that provided care for me and my family, and allowed me to make enough money to pay my premiums, but if I ever got to a situation where I could not get coverage, I would be pissed. And so I am 100% agreement that we needed to address that with regulations.

            After that, the only problem with our healthcare system is the cost of healthcare. And Obamacare did nothing about that. Obamacare actually increased the long-term cost of healthcare for all.

            And so even after spending trillions, we will still have US liberals screaming that we need to do more… more of the wrong things that perpetuate the problems.

          4. Don Shor

            We have Obamacare and yet you are still complaining about people without coverage.
            Why do we have people without coverage?

            Because some governors refuse to accept the federal expansion of Medicaid for their poorest citizens.

          5. Don Shor

            if I ever got to a situation where I could not get coverage, I would be pissed. And so I am 100% agreement that we needed to address that with regulations.

            If you make the rule that pre-existing conditions have to be covered, everybody’s health insurance will cost far more unless you expand the risk pool by means of the individual mandate. Insurance companies were controlling costs by throwing people off plans, refusing coverage, refusing treatment.
            Every time Republicans try to come up with a replacement for the ACA, this is the conundrum they face. The individual mandate is the key to expanded coverage for those above poverty level, and the Medicaid expansion is the key for those below poverty.

          6. Frankly

            Me: We have Obamacare and yet you are still complaining about people without coverage.

            Why do we have people without coverage?

            Don: Because some governors refuse to accept the federal expansion of Medicaid for their poorest citizens.

            Wrong.

            We still have people out of coverage because it was a lie that Obamacare would cover 50 million people without coverage… a lie that was called out over and over again and you and others argued against it.

            But before that you are wrong because the root cause of people out of coverage is that they don’t make enough to pay for their own coverage.

            And if you don’t make enough to pay for something, that something needs to cost less or you need to make more.

            So then… how do we fix those two problems?

            And guess what, if we fix those two problems we also fix the other problems of “fairness” that liberals cannot seem to stop complaining about.

            We spent trillions to fight the war on poverty and yet liberals complain every year that poverty is growing… and now instead of lacking enough food, it is “food insecurity”.

            Grow the economy and foster market competition where there is adequate supply and copious choice and we fix most of those problems.

          7. Don Shor

            So many distortions.
            Ok, so the cause of people not having insurance is that they cannot afford coverage. Or, as you put it,

            the root cause of people out of coverage is that they don’t make enough to pay for their own coverage.

            Duh. This is like saying that the cause of poverty is that people don’t have enough money.
            Yes, it would be great to grow the economy enough that more people have more money. But there will always be poor people who can’t afford health insurance. There will be more of them during times of economic downturn than during times of recovery. But there will never, ever be a strong enough economy that everybody will be able to afford health insurance. Not under a president Reagan or Bush or Obama or Clinton. So your statement is pointless.
            The failure of Republican governors to accept the Medicaid expansion leaves millions of Americans without coverage. Mostly in Republican-run states. Mostly in states with high levels of poverty.

          8. TrueBlueDevil

            Frankly, tell me if I am wrong here.

            One way to reduce costs would be to allow bare-bones medical coverage, i.e., catastrophic care. I think this would help a lot of people. I can get my Flu Shot at CVS or Costco, and many can pay for the basics on their own. Its not what they’d prefer, but they can manage it. They can pay a local provider, clinic, or nurse practitioner when they get the flue, a hang nail, or even a broke arm. What they need protection for is if they get cancer, diabetes, or a broken back. We don’t need hair transplants covered (one state required this).

            Related to this is allowing cross-state competition. What did California have, 3 health insurance providers? We should have 15, 20, 30!

            Published pricing, I think this is key. As consumers, how can we shop, if we don’t know the price – to go along with the quality?

            More Medical Schools. If Obama were serious, he would have come up with a way to double the number of grad students in medical schools.

            ERs: We need a way to cut down on illegal immigrants using the ER when they get the flu. Would more low-cost, local medical clinics help?

            Health savings accounts – another key component to folks helping themselves and bettering their health.

            Obama had 4 or 5 goals with the ACA, and he failed hitting all of them. I believe the biggest was insuring more people, and his made-up number of 40 or 50 million has only been whittled down by 1 or 2 million. Pretty bad.

            Wait until even higher rates kick in when government guarantees to insurance co’s fall away.

          9. TrueBlueDevil

            Don: The Halbig case (Halbig vs Sebelius) working its way through DC district courts could undermine Obamacare.

            The law was written so that subsidies could only be given to those buying state insurance, not federal insurance. Like many provisions and parts of the ACA law, this is being ignored. It will be interesting to see, and maybe Obama will use another illegal executive decree to keep his baby moving.

            BTW, has anyone read Blood Feud?

          10. TrueBlueDevil

            If Obamacare is so great, why did the Congress, Obama, and Congressional staffers exempt themselves from it?

        2. Frankly

          Sorry Tia – I thought I remembered that your daughter worked for a non-prrofit that did not provide health care services and did not pay very much.

          Sorry about her health problems. I know what that is like having a child with severe health problems.

          Thankfully you and I make enough to provide assistance to our adult children.

  9. Tia Will Post author

    Frankly

    “Medicine is different, but there it still would be better served with competition. ”

    I don’t see how you can reconcile this view with your stated approval of the Kaiser system. Our entire system is built upon collaboration between doctors and hospitals, not competition.
    Since each of us gets paid for our time, not the exact nature of what we are doing during that time, there is no incentive to “be the best” in everything that we do. Because I make exactly the same amount of money whether I am submitting a consult to a colleague who I know is better at laparoscopic procedures than I am as I would doing the procedure myself, I have no incentive to provide anything but the best possible care for the patient.
    This is certainly not true in a competitive, fee for service, free market system. With a Kaiser model, there is no incentive to order more tests, do more procedures than are necessary, try to convince yourself that you are the
    “best” laparoscopist because you just attended a seminar. Yes, all of these things are typical of fee for service medicine. You just don’t see that because your fee for service provider is not going to tell you.
    I am. I have been asked many times if I am going to be the providing surgeon and answered truthfully, No, because I am not the best person for that job. And then I happily, and without any risk to my income, refer them to the best.

    You just stated that doctors had not done a good job of holding down costs and I could not agree more.
    The Kaiser model is one that allows us to do just that through collaborative integrated services, not through competition.

  10. WesC

    The United States health care system is the most expensive in the world, but a 2014 report by the Commonwealth Fund and prior editions consistently show the U.S. under performs relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in 2010, 2007, 2006, and 2004. The U.S. is last or near last on dimensions of access, efficiency, and equity.

    The Universal Healthcare govt run program in Britain on the other hand ranked 1st in effective care, safe care, coordinated care, patient-centered care, access, efficiency, and equity. The UK had per capital health expenditures of $3,405 vs. $8,508 for the USA.

    In comparing our own govt run plan for the elderly known as Medicare with private insurance the Kaiser Family Foundation found that administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue. Insurance industry-funded studies exclude private plans’ marketing costs and profits from their calculation of dministrative costs. Even so, Medicare’s overhead is dramatically lower. Medicare administrative cost figures include the collection of Medicare taxes, fraud and abuse controls, and building costs.

    So-called “competition” in the private health care market has actually driven costs up. In most local markets, providers have monopoly power. Consequently, private insurers lack the bargaining power to contain prices.
    In most areas, two or three dominant insurers dominate the regional market, limit competition and make it extremely difficult if not impossible for new insurers to enter the marketplace and stimulate price competition.
    Medicare Advantage, which enrolls seniors in private health plans, has failed to deliver care more efficiently than traditional fee-for-service Medicare. Both the CBO and the Medicare Payment Advisory Commission (MedPAC), the commission which advises congress on Medicare’s finances, have calculated that Medicare Advantage plans covering the same care as traditional Medicare cost 12 percent more.

    1. Michael Suhany RHU REBC ChHC

      All you are comparing is the cost of care. The other variables are so great so as to make this comparison meaningless.

      Please also address the issue that Medicare reimbursement levels are less than the actual cost of care. Tell me what would happen to healthcare in the United States if all healthcare were to be reimbursed at Medicare Reimbursement Levels.

      And what you fail to note is that Medicare Advantage plans cost more because they provide seniors with an out-of-pocket maximum and far higher level of service than Medicare alone.

      1. WesC

        MS: All you are comparing is the cost of care. The other variables are so great so as to make this comparison meaningless.

        These and many other studies have included all of the relevant variables and their conclusions have been deemed valid.

        MS: Please also address the issue that Medicare reimbursement levels are less than the actual cost of care. Tell me what would happen to healthcare in the United States if all healthcare were to be reimbursed at Medicare Reimbursement Levels.

        I do not know of a single hospital that refuses to accept Medicare or Medicaid patients. If all of the healthcare were reimbursed at the Medicare rates, there would probably be more mid-level practitioners taking care of routine, stable, non-complex patient problems. You would probably not get an MRI every time you sprained your ankle or twisted your knee. You would probably not see a lot of duplicate services available within a defined geographic area, and you would probably not get referrals for specialty care on demand regardless of medical need. Last but not least we would all have a little more disposable income in our pockets.

        1. Michael Suhany RHU REBC ChHC

          If you think you have an apples to apples comparison between care today in the U.S vs. care in the U.K., for example, I can’t help you. See what you want to see.

          Why are there no hospitals that refuse to accept Medicare patients? Not because Medicare reimburses at a level equal to the cost of providing care. They are under compulsion to do so.

          If all care were reimbursed at Medicare rates, watch innovation and excellence exit the U.S, healthcare market.

          Why do people in the U.K. buy supplemental health insurance to provide themselves with better healthcare than comes to them with their access to the NHS?

      2. Tia Will Post author

        Michael S.

        As a Kaiser doctor, I have a completely different perspective on this.

        In my opinion, if all care were reimbursed at Medicare rates, we would have eliminated one of the problems that Frankly has cited. Doctors have done, as a group, a terrible job of holding down rates. We have artificially maintained salaries at high levels by maintaining a known shortage of training slots in both medical schools and residency programs.
        In fee for service medicine we have continued the practice of bringing back patients year after year for office visits, tests and procedures that are of no demonstrated benefit, but which generate income. We have ordered far more tests than needed because these also generate income. We have continued the practice of sending patients for specialist consultation when a telephone consultation or electronic communication would have sufficed.

        I will give you one simple example from my practice. I have special expertise in breast evaluation and screening for cancer gained over 16 years of focusing on this area. Unlike what would occur in fee for service medicine, I do not get paid any extra for providing this consultative service to my colleagues. On Friday, I happened to be in the office doing administrative work but was not scheduled to see patients. One of my colleagues wanted a consultation on a breast complaint. I saw the patient in real time in her office. This did not cost the patient a penny more than her routine co-pay. This would never, never happen in the fee for service world where she would have had a referral sent. She would have been seen in the office of the specialist frequently eliciting a co pay two to three times that of the generalist who had initially seen her to receive exactly the same recommendation that the original provider and made since she nailed it but just wasn’t 100% sure.

        This kind of waste and inefficiency can be eliminated without decreasing the income of the individual provider or by costing the patient or her employer more. It is based on an integrative practice, the belief that the best time to provide a service is when the patient is already there with no delay for insurance pre approval of what the provider already knows is the right thing to do, belief in collaboration over competition between providers, and economies of scale.

        I also feel that you are in error that innovation and excellence will leave the country if reimbursement rates are lower. Again, I will use Kaiser as my evidence. No doctor joins Kaiser to get rich. The vast majority of us could have made more money in the fee for service model. However, there are many of us in Kaiser who are major innovators and researchers. One of our Oncologists provided the research and expertise that has led to the current revision of cervical cancer screening guidelines which have saved millions of dollars by proving that women in certain risk categories could safely come in for testing every three years as opposed to every year which was the practice 25 years ago.
        One of our local doctors is a nationally acknowledged expert in hospital safety.
        One of my department was last years President of the ACOG – not a position that one gets without being an acknowledged leader in our field.

        Doctors can thrive in a setting that is not totally dependent on the continuous need to acquire more money by doing that which does not need to be done.

        1. Michael Suhany RHU REBC ChHC

          Dr. Will,

          The Milliman studies that I have read indicate that Medicare and Medicaid rates cannot sustain the medical system in which we exist.

          This is not to say that our current system has not been skewed by our current reimbursement methods and that change is not possible. Witness this article about reimbursing PCPs more to manage their patients with complex medical conditions – http://www.pbs.org/newshour/rundown/will-health-reform-shine-new-light-primary-care-physicians/.

          I agee with you that the model that Kaiser follows is the way forward if we wish to continue to enjoy the same quality of care to which we are accustomed at a price that we can still afford. The question is how to move the entire market in this direction.

          And what do we do with stories like this – http://nymag.com/news/features/cancer-peter-bach-2014-5/. Do we have unlimited funds to give Ruth as many days as possible of whatever quality with as sure an outcome when we could have immunized how many children or screened how many indivuduals for preventable medical conditions with the same dollars?

          All healthcare is rationed. All we are deciding is who does the rationing and the basis on which they are making their decisions.

          Except in America where I have unlimited annual and lifetime maximum coverage coverage for any medical procedure once it is deemed acceptable medical practice and no longer experimental regradless of its efficacy.

          And if you have ever had a patient receive an orthopaedic implant, there is better than a 50% chance that it was developed if not manufactured within 10 miles of where I live. I say that because there are many companies that would steal away those engineers skilled in designs involving titanium or highly paid polishers with a high school diploma if their firms were not paying market prices for their labor.

          I say all of this just to point out how complicated the situation is. Please don’t take anything I am saying as a person challenge to your practice with your patience. Just like my own healthcare providers, I think you are trying to provide the best care you can in the situation that we find ourselves today while working to make it better for tomorrow.

  11. Michael Suhany RHU REBC ChHC

    There is merit to the argument that the marketplace as it exists in the United States has driven both innovation in treatment and access to care at least as it applies to those who are insured. The problems are the inefficiency in that system and the uneven access to care as experienced by the uninsured.

    I live in a small town in a fairly rural area of my state. By God, I could have an MRI at my local hospital this Saturday afternoon if the ER doctor though it advisable. If I have an automobile accident this Saturday afternoon and an EMT thinks it advisable, they can call on their choice of two air ambulance services to fly me to a hospital less than 50 miles away by ground ambulance. It takes a huge amount of excess capacity at a huge cost to provide those services, but I am so down with it as a consumer.

    Then there is the question of the uninsured. We need to distinguish between healthcare as a social good and healthcare as a human right. It is the former and not the latter and needs to be advanced as such.

    And then there is the matter of what we can afford. We are a society intent on living beyond our means whenever and wherever possible. Maybe it is the best that is the enemy of the good.

    1. Tia Will Post author

      Michael S.

      “We need to distinguish between healthcare as a social good and healthcare as a human right. It is the former and not the latter and needs to be advanced as such.”

      I was with you until this statement. What you posted previously was factual. This is clearly a matter of personal opinion and it is one that I do not share with you. Much is made in this country about our Christian principles.
      Now it is true that there is precious little in the way of direct quotes to quid as us to Christ’s position on our responsibility to provide heath care. However, as actions frequently speak louder than words, I believe that
      Jesus, who was himself a healer as were a number of his disciples, were by healing the sick without requirement for payment, showing us the path of moral behavior. I fail to see how one can adhere to Christian, or really any moral belief system that is not totally self centered and not believe that health care is a human right.

      1. Michael Suhany RHU REBC ChHC

        Here is what I mean by pursuing a social good versus enforcing a human right.

        In the pursuit of a social good, we will assent to a reduction of our individual freedoms for the overall good of society from which we wll all generally benefit. In the pursuit of a human right, we will assent to the surrender of our individual freedom for the benefit of a privileged class regardless of the benefit to the whole of society.

        I will assent to purchasing a health insurance policy that covers Essential Health Benefits that I may never need and at a higher premium that otherwise nesessary so that everybody else may do so as well. That is pursuing a social good.

        Here is the pursuit of a human right.

        I will pay whatever the government tells me I better by God pay for health insurance so that the person who refuses to buy insurance can get whatever treatment they want whenever they need it.

  12. TrueBlueDevil

    If you read the literature, we have by far the best survival rates for serious, life threatening illnesses. This is but one example. Wealthy, and even middle class citizens of even Britain and Canada come her for medical procedures.

    Our statistics are also heavily impacted by a defacto underclass in many urban area, and our illegal immigrant population which numbers anywhere from 20 to 40 million.

    1. TrueBlueDevil

      If you look at how many Americans lost their coverage when Obama and the democrats lied to us, the addition of a million or two new signees is disastrous. We could have far surpassed this number by simply expanding Medicaid.

      The fact that we can’t say which country we want to model ourselves after is telling.

      1. Tia Will Post author

        TrueBlueDevil

        “The fact that we can’t say which country we want to model ourselves after is telling.”

        Is telling of what ? There is no one system that will be the perfect fit for the United States.
        The point from my perspective is to look at the practices of those countries that are doing better than we are in particular metrics, consider all the factors contributing to their success and implement those that are applicable.

        This is in stark contrast to our current practice of xenophobic name calling and pretending that we of course must be doing everything better than a socialist country.
        We do somethings better. We are worse at others. Why should this be so terribly difficult to admit ?

      2. Tia Will Post author

        TBD

        “if you look at how many Americans lost their coverage”….

        Please cite your numbers and the sources of this information as well as the numbers that have not been enrolled in another plan.

        I ask because this is simply not what I am seeing. I am willing to grant that my personal knowledge only encompasses Northern California exchanges, but under Covered California,
        this does not seem to be the case with new enrollees and individuals having accepted new insurance through the exchange far outnumbering those who lose their insurance and then do not re enroll.

    2. DavisBurns

      You mean we have access to expensive medical treatment but not much for follow up and routine care. Case in point: heart attack and anoxia result in. 6 day in hospital with.3 in intensive care with two days of one nurse assigned to this one patient. Follow up care? She will see a neurologist 8 months after release from hospital. In England she would have a center that deals with anoxic brain injury to support her and her family and she’d see a neurologist for follow up care right away. Here we get a wiki walk for support.

      1. Tia Will Post author

        DavisBurns

        I am so sorry if this happened to a family member or someone you know. It does not have to be that way. My daughters story was as follows: With her permission, I had alerted my daughters primary care doctor of my concerns since she was at that time still in the typical denial mode of this disease. Her initial labs came back normal, but with continued weight loss and the very real prospect that she could die, we convinced her to voluntarily admit herself. She was hospitalized for over a month covered by my insurance. Fortunately there was no end organ damage. She qualified for and attended an intensive outpatient therapy first daily and then several times weekly. She ultimately failed this outpatient program and re-admitted herself to the hospital. On the second time out, with intensive therapy she was able to stabilize her weight and has been slowly, slowly recovering over the past 2 years.

        Unfortunately, during her illness I met a number of girls who were not fortunate enough to have insurance and who were literally making frequent ER appearances to have their electrolytes balanced enough to be stable for ER discharge, until the next episode when their heart rate hit the 30s or 40s and then were in the ER again for hydration and electrolyte balancing.

        Unlike Frankly, I do not believe that there are many women in their 20’s who will have managed to earn enough money to pay out of pocket for these > $ 150,0000 hospitalizations . And also unlike Frankly, I am not so naive as to believe that a new college graduate will be very likely to find a job when she presents for her interview at 5’3″, weighing 74 lbs and so ill that she passes out on a regular basis. But then, I am not a private businessman, so what do I know ?

        1. DavisBurns

          Tia, thank you. This is my 27 year old daughter. She has Medi-cal. The hospital cost her nothing which is good because she has nothing. The hospital care was, with one exception, excellent and while her GP (who has left Sutter and gone to Kaiser) was also excellent and diligent, the follow up with specialists has been spotty. She has so many specialists it is daunting to consider changing providers. Once we got the specialists scheduled, she had about 9 appointments per month for several months. Why the neurologist is taking so long is a mystery but my point remains–we do much better with crisis medicine than maintenance and the co-ordination of care.

          I also want to point out that ACA was meant to help those who could pay for insurance if it wasn’t too expensive and those who had pre-existing conditions. The very poor have medicaid and in some cases medicaid and medicare and since we have expanded the numbers living in poverty, we have expanded medicaid. I think it has been successful in helping those targeted groups. It is also a pro-business law. Providing insurance is an expensive proposition, as I know from having offered it to our employees. It reduces operating costs when businesses have the option not to provide medical insurance. We are shifting the costs onto the shoulders (pocketbooks) of employees and this act facilitates that move. The government is not willing to provide universal health care (we have businesses that re-locate to canada because their overhead is lower when they don’t have to pay for health care directly and it is cheaper to pay higher taxes when healthcare is included in the tax bill). The government, being pro-business, is shifting the burden to the individual. I don’t see why the conservatives have a problem with the plan. It was conceived by republicans and provides subsidies for business and the insurance industry. Much like low income housing, for profit companies make a guaranteed income and the housing of the poor is simply a means to that end. Food stamps, until recently was a program administered by the USDA, implemented to subsidize farmers and food manufacturers and retailers; feeding the poor was a means to an end. Now we have ACA, relieving profit making entities from providing a benefit and giving insurers a windfall. We need our underclass as profit making opportunities, just as we need our prisoners to fill for-profit prisons.

    3. Tia Will Post author

      TBD

      ” Wealthy, and even middle class citizens of even Britain and Canada come her for medical procedures.”

      And we have patients both wealthy and middle class who choose to go out of the United States to “medical resorts” to have surgeries such as hip replacements done because they can get care of equal quality for much less than they would pay here. Does that mean that our care is inferior ? Of course not. It is a matter of personal choice.
      Many go outside the US because the cost is a major factor for them. I am sure that some folks who come here for elective procedures come because timing, not cost is the major issue for them.

    4. Tia Will Post author

      TBD

      “If you read the literature”….

      Which literature please.? I can guarantee you that I read a lot of literature and this is not the conclusion at which I would arrive.

  13. DavisBurns

    I have a friend who has a diagnosis that let. Kaiser put her in a high risk category. She is fit, swims with masters, cycles and doesn’t need frequent doctor’s visits but she couldn’t let coverage lap. Her premiums went down several hundred dollars per month under ACA allowing her to pay off a second mortgage and save for retirement. Same coverage, less than 50% Less. Meanwhile her friends who had affordable coverage all these years bitch about their premiums going up 5%. ACA worked best for those who worked, could afford insurance but weren’t part of a group. My husband and I have been self-employees for 30 years with an exception of a couple of years. We have a daughter with HCM who got her first pacemaker at 18 months. The prime directive of my life was ‘don’t let her die’ closely linked with don’t let medical insurance lapse cause there could be a heart transplant in her future. It’s a stressful way to live.

  14. Tia Will Post author

    DavisBurns

    I sincerely hope that we, as a society, will continue to take the steps to ensure that people in your circumstance
    will never again have to worry about whether or not their child will be cared for due to our insurance coverage or our individual ability to pay.

  15. South of Davis

    Tia wrote:

    > The ACA is a large program with a number of provisions. As with any
    > large, complicated structure, it has some good features and some that
    > may not work out so well.

    It seems to me that the ACA is just hiding the health care problem for a little while. We need to reform health care so they can’t hide prices, fix prices restrict trade (good luck selling the EXACT same over the counter meds you got in Canada for $10 that sell for $200 here).

    I was self employed in the late 90’s and paid under $100/month for health care, ten years later when I was self employed again I called the same broker and it was just over $1,000/month for a similar policy. Today I pay almost $2K/month for family policy that only covers 70% after the deductible.

    My kid recently had a cup of tea fall off the counter and burn the skin. My wife wanted to see a MD so she took the kid in and we paid $600 to have an MD spend 15 min putting some white stuff on the burn and wrapping it up.

    I know Tia and other MDs spend a lot of time in School, but there is something wrong when it costs more to have a MD look at your kid for 15 minutes than it costs to take a limo to SF and stay in the Fairmont Hotel and have a lobster dinner…

  16. Tia Will Post author

    South of Davis

    You will not find anyone who agrees with the point that you are making about cost than I do.

    What I would have recommended to you and your wife is that you snap a picture of the burn, call me or send me an electronic message with the picture attached. I would then have looked at the picture and advised you how to take care of it all electronically. All without costing you anything above your premium. All without lessening my income at all.
    And you wonder why I love Kaiser and have never considered a career in any other setting since I was first introduced to the model 28 years ago ?

    1. South of Davis

      Tia:

      Thanks for the offer, but even after I consulted “Dr. Google” and showed my wife kids with worse burns that didn’t have to go to the hospital she still wanted to go. Since I know that “if it is something you can pay to fix it is not a real problem” and “if you have a happy wife you have a happy life” I told her “if it will make you feel better go to the hospital”

      As far as “cost” Kaiser seems better than most , but I have seen some just AMAZING bills over the years including one for over ~$24K after a co-worker was rear ended on 101 in Marin at about 6:00pm and released at about 6:00am (after a TON of tests).

      If it costs ~$2K/hour (to be fair it was a little less since close to $1K was for the 3 mile 5 minute ride in the ambulance) or about was the average working American takes home in a year to “test” a guy that got “hit hard” but was able to come in to work the next day for an hour we are doomed…

      1. Tia Will Post author

        TBD

        Are you serious when you say if Obama were serious he would have found a way to get more students into medical schools ? Can you imagine the outcry from the right about how he was staging a take over of medical education and how his policies were going to ruin medicine and lower the quality of doctors.

      2. Tia Will Post author

        South of Davis

        With this story you have touched on three major issues that drive up costs unnecessarily:
        1) Costs are not provided up front. I think that many people might decide that an experienced ER doctors exam and may be a simple X-ray would do rather than a CT or MRI if they knew
        how much these cost.
        2) Doctors themselves are apt to order too many unnecessary tests, both because we genuinely do not want to miss anything that would harm the patient, but also because of malpractice allegations, which are frequently made on the basis of a bad outcome, not negligence.
        3) A fee for service model provides incentive for ordering more tests than needed.

  17. Tia Will Post author

    South of Davis

    “It seems to me that the ACA is just hiding the health care problem for a little while. We need to reform health care so they can’t hide prices, fix prices restrict trade (good luck selling the EXACT same over the counter meds you got in Canada for $10 that sell for $200 here).”

    However, I do not share your view that the ACA is “just hiding the health care problem …”
    I believe in steps that can be accomplished. The American people have been so sold on the false idea that we have “the best health care system in the world” and that anything occurring in any “socialist country” must be evil and inferior to whatever we have, that there was no possibility at all for getting more comprehensive reform at this time. So as I realist, I will take, and work with what I can get. But rest assured this will not be the end.
    There are many of us who do see health care as a human right, who do believe that we should take care of those who are in need regardless of their ability to pay or their insurance status, that slowly, slowly we will be able to move in a more humane direction for our country just as occurred when social security was enacted, and just as happened with both Medicare and Medicaid. It is just a matter of time, individual stories and patience….lots and lots of patience.

  18. Topcat

    WesC wrote: “The Universal Healthcare govt run program in Britain on the other hand ranked 1st in effective care, safe care, coordinated care, patient-centered care, access, efficiency, and equity. The UK had per capital health expenditures of $3,405 vs. $8,508 for the USA.”

    Britain’s program is the National Health Service, commonly known there as the NHS. I am somewhat familiar with the system as I have a close family member who underwent a major procedure there in May and June of this year. I was there and was in the hospital. From my personal observation, I can tell you that the hospital was very clean and modern. The staff was extremely helpful and friendly and they appeared to be very competent and efficient. I was impressed by how professional and knowledgeable and caring the doctors and nurses were. We even had an MD call in the evening when there was a small issue to resolve. I have NEVER had an MD call in the US after hours.

    The big difference that I noticed was that there was NO talk of who was going to pay. There was no insurance company involved and no paperwork related to payment. The medical providers do not have any incentive to order unnecessary tests or procedures. From this point of view, I think that the NHS is a much more efficient system of providing healthcare than what I have experienced in the US.

    My relatives in the UK feel that the NHS does have it’s problems, but overall they are very pleased with the system and the care they receive.

    I think that we need to recognize that the patchwork system we have in the US is extremely inefficient and there is a tremendous amount of overhead and waste. Perhaps we could learn something by looking at the good parts of systems such as the NHS.

    1. Frankly

      Topcat, there are a lot of moving pieces and differences with US healthcare that would have to be addressed before a UK-style system would work here.

      And the UK system would suffer should the US go to its model. Because the US system is the land of medical procedure, technology and drug advancement entrepreneurialism. Sort of like the US military. We protect the rest of the world so the can sit in smug criticism of us for not being more like them.

      Lose the medical advancements brought to us by the engine of US healthcare, and those advancements would largely just go away. Or they would be developed in China and would kill 3.9% of the people that take or use something new because of the lack of testing and control processes.

      And what I understand about UK healthcare is that you wait a long time to see a specialist. And the costs are unsustainable.

      France for example does not cover everything and French people have to buy supplemental insurance.

      Canadians with money flock to the US for their special procedures. The Premier of the Nova Scotia skipped out to get a laparoscopic heart procedure because in Canada they still cracked the chest.

      No system is perfect. And most people report satisfaction with their healthcare system as is.

      1. Tia Will Post author

        Frankly

        “Canadians with money flock to the US for their special procedures.”

        And Americans with money flock to “medial resorts” to have surgeries performed in spa like settings for much less than it would cost in the US.
        Medicine, like many industries, is becoming progressively more “globalized”. This is not the “one way street” that it may have been in the past.

      2. TrueBlueDevil

        I saw a blog post from the UK where a woman was in pain, and it took 18 weeks to see the first specialist, and 18 weeks to see the second specialist. There were 4.5 million hits on the long wait times in the UK. This is one of the primary drivers of patients from the UK or Canada to come to US hospitals.

        A friend from Cleveland asked me what the top hip replacement center is for Canada. It was either the Cleveland Clinic, or Mayo Clinic.

        A few years back my GP wanted me to get a test with a cardiologist, and my wait time was going to be one week. A phone call got it reduced to 2 days for the test, which showed that my ticker was fine, but another 10 days for the official sit-down doctor’s visit.

        1. DavisBurns

          My daughter’s defibrillator shocked her in January 2013 at 9:43 am. It is a painful event. She contacted her GP that day and saw her soon after. Every day thereafter for 5 months, her body beeped at her at 9:43 am until a pacemaker representative finally agreed to make an office visit and reset it. My daughter is disabled, she lives on SSI which is designed to humiliate and make you understand you are a leech. These are people who cannot work, like my daughter. The county has a program to help with phone service. She can choose a land line but she cannot make a toll call. The ICD can be checked and reset over the phone however they will not initiate the call. My daughter had to make the call. With the service provided, she could not make the call. She had another option for a low cost phone. She could get a used cell phone with limited minutes. The cell phone was unreliable but she could make a call to Sacramento. Of course,the ICD cannot be checked over a cell phone. To everyone who thinks they know something about access to care in this country, I say, first walk a mile in the shoes of the people on the bottom of the system. The barriers to care are immense and the delays can be life threatening.

          1. Frankly

            DavisBurns – I am truly sorry about your daughter’s situation. Kids with serious health problems one of the most difficult things. As parents we spend our lives trying to protect our children, and then we get hit with something we have no control over… well have limited control over.

            I would like more control over it. I would like a free marker where I could seek out the best programs and best specialists to get the best care possible. I am willing to pay more for that better care. But I would also shop on value. For example, if my son needed an MRI, I would shop for the best price for an MRI. And the cost difference is astounding for reasons that don’t make any sense. A colonoscopy at Sutter Davis is $10,000… in Sacramento it is $3,000. It took me an act of Congress to find that out.

            I see a lot of misplaced frustration from people demanding reform. They are blaming the system and demanding that their government fix it, but the solutions being pushed are in fact going to just increase the frustrations.

            If you honestly and factually list out the problems with healthcare service today, it comes down to access and cost. And much of the access problem is just a manifestation of cost.

            If we all were pushed to HSA style plans and the government implemented policies to demand that all providers fully publish the cost of all service and products, and if the government used tax incentives to help do some economic class leveling… then we would solve many if not most of our problems.

            Our GP should be our preventative care provider and our care coordinator. And we should have a lot of choice for where to do for specialty health care. We are going the exact opposite way were our GP will be less available and our choice will be even more constrained. And any frustration we have today is going to be amplified in the coming years.

            Government is not a loving organization. Those that keep looking to government to improve care are making a mistake.

          2. TrueBlueDevil

            DB, I’m also sorry to hear about your daughter’s plight.

            But what percentage of SSI and disability payments are frauds?

  19. WesC

    We pay exorbitant amounts for healthcare because industry groups like big pharma have undue influence in Washington.

    For example India, Egypt and Brazil have secured access to Sovaldi, which is a incredibly effective, but also incredibly expensive hepatitis C treatment, for one percent of its cost in America. The 12-week treatment program that runs U.S. insurance companies $84,000 per cycle, will be just $840 in those nations. Burma, Kenya, Mozambique and Iran will pay slightly more: $900 for the full treatment program, or 1.1 percent of the standard price. The British cost is $57,000 for a full treatment, Germany $66,000 and Canada $55,000. The company’s reduced prices came after the World Health Organization worked with Gilead directly to help spread the drug’s usage. So what determines who gets a discount and who doesn’t? It’s simple. Gilead admits their “global pricing model is based on a country’s ability to pay.” Pricing policy for drugs is simply a matter of charging as much as the market will bear. Obama went to bed with the mafia when he got big pharma to not oppose the ACA in return for a hands off policy on drug pricing.

    The often quoted arguement that all of these outrageous prices pay for research is not completely accurate. A 2008 study by 2 New York University researchers estimates the U.S. pharmaceutical industry spends almost twice as much on promotion as it does on research and development, contrary to the industry’s claim. The U.S. pharmaceutical industry spent 24.4% of the sales dollar in 2004 on promotion, versus 13.4% for research and development, as a percentage of US domestic sales of US$235.4 billion. The study’s findings supports the position that the U.S. pharmaceutical industry is marketing-driven and challenges the perception of a research-driven, life-saving, pharmaceutical industry.

    You could pick any other part of health care in this country and the story would be the same.

    1. TrueBlueDevil

      How many new life-saving drugs are developed by India, Egypt and Brazil?

      How about even France or the UK?

      A friend paid a modest price for a drug he uses, but it’s patent protection just ended, and the generic price dropped by 85%.

  20. tribeUSA

    Re: costs–each year I need to see a dermatologist for a skin cancer screening (I had a minor nonmalignant basal cell carcinoma a number of years ago). In the past couple of years, the bill for seeing a dermatologist for about 15 minutes total time was $900, with about 2-4 minutes of time taken to visually screen my face and torso for skin cancer (pretty fast considering I have lots of skin blemishes that need to be distinguished from precancerous lesions), 3-6 minutes to freeze off several keratoses and possible precancerous lesions with shots of liquid N2 from a spray bottle, and 3-5 minutes of talk. My insurance at the time payed about half; I paid $450 out of pocket for each such short visit (I’ve since switched to Kaiser; hope they are less expensive!)

    I compare this with dental costs–the rate ($/time spent with dentist examining/treating me) I’ve been charged seeing various dentists over the past few years has been 10-20% of that for the dermatologists; I’ve had tooth problems and the dentists have done very fine high-precision work; including treatments that definitely require a lot more skill than spraying a skin lesion with liquid N2 (I’ve had the good fortune of seeing excellent dentists that have a laserlike focus and take pride in their job and workmanship on my teeth and don’t rush me as a patient; in contrast with several dermatologists I have seen).

    1. WesC

      Good luck with your Kaiser Dermatologist. I had Kaiser and had a squamous cell carcinoma that was greater than 5mm deep via a biopsy. The Kaiser Dermatologist wanted to remove the residual cancer cells with a punch biopsy needle, and after the Head and Neck surgeon cut out a much larger area still said I didn’t need any Derm. follow-up or annual screening. Haven’t had any better luck with UCDavis Medical Group. My primary care provider would not refer me to a Dermatologist for screening which I had not had for several years and insisted he could do it himself. After his “all clear” screen, I did not feel comfortable and paid for a out of network Dermatologist appt a few months later only to find out that a mole which was clearly visible on my shoulder and with classic warning sign characteristics turned out to be melanoma.

      The lesson of the story is that unless you are willing to learn about your own healthcare or have someone who you trust who can do this and advocate for you, do your research to find competent providers, and are also willing to fight your provider and insurance company for the community standard of care, whether you receive competent care or not will be determined by how lucky you are.

      1. tribeUSA

        WesC–aargh, what a horrible scary experience & this is not what I hoped with Kaiser! How strange that your primary physician would not refer you for routine annual (or more frequent) screening despite your history of what sounds like a moderately serious squamous carcinoma–when I had my small and superficial basal cell carcinoma surgically (just local anaesthesia and a total procedure time of about 15 minutes; with excised material then sent out for immediate biopsy) excised a couple of decades ago, my dermatologist recommended annual screenings for the rest of my life; so far I have been following this and making sure to get checked every year.

        Yes, good thing you took your healthcare in hand; and be sure to get screened every year (or twice per year considering your more serious history); hope you have found an excellent dermatologist you can trust now.

      1. WesC

        What are you trying to say?? I did state that I did go out of network. I did end up paying over $700 out of pocket. For your information the cash price hospitals and providers charge is usually significantly higher that the negotiated rate that insurance companies pay. Do you actually think you get a discount if you go to a provider in a rural setting?

  21. Tia Will Post author

    WesC

    I think that your story is a good representation of a universal truth about medicine. At its best, it is a collaboration between the patient and the doctor. The doctor is the “expert “on medicine, the patient is the “expert” on his/her own body.

    The ability to make a mistake, or misdiagnosis, is a universal human trait and is not dependent on the the system with which the doctor has their practice. I always make a point of telling my patients that I can be mistaken, so if a condition does not clear up as anticipated with a given treatment within the anticipated time frame, they are to notify me so that we can move on to the next step promptly.

  22. TrueBlueDevil

    I’m glad that your daughter is doing better. However, the example you gave regarding her illness, the costs and repercussions reminded me of the exaggerations that were used to pass the Affordable Care Act.

    I did a quick google, and webmd placed the number of cases of anorexia that end with a fatality at between 5 to 20 percent, which is a huge gap. The National Eating Disorders organization puts the rate of mortality from anorexia nervosa at 4.0%. Certainly a deadly disease, but not at 20 percent. Studies are all over the board, but the 4% figure comes from data extracted from death certificates.

    Likewise, the first national eating disorders organization I looked at put the cost of treatment at up to $100,000 or more, a 1/3 reduction from the number you used. Daily costs for treatment were pegged at between $500 to $2,000 per day. Obviously there are various stages of anorexia, but again there is a wide range of cost. Many patients choose outpatient services because their symptoms were caught earlier, and the costs are much lower.

    I also found it interesting that you figure this illness would drive you to bankruptcy when there are many other plausible factors to consider. First, your daughter is an adult who could pay for her own treatment and health care. At her age, she could have had a health care package for a song with a free market system before the ACA act was even signed! Either way, she could pay for it. Both you and eventually she will have lucrative professions that put her in the top 2% or 1% of our society, so paying off the debt for saving her life would not entail bankruptcy. If you add in your husbands income, that makes it even more manageable. I can see a painter or cook having to declare bankruptcy, but not three well-paid professionals.

    This reminds me of the blatant lies that President Obama told us in 2008 when he was selling us the ACA Act. Our President told us that his Mother was denied payment for her cancer treatments because it was considered a pre-existing condition. Actually, it was uncovered that her HC provider paid most of the costs with no fanfare. There were also stories and implications made that she died because she was denied coverage, a bald-faced lie.

    Here is one of the lies Obama told us in a debate with John McCain: “For my mother to die of cancer at the age of 53 and have to spend the last months of her life in the hospital room arguing with insurance companies because they’re saying that this may be a pre-existing condition and they don’t have to pay her treatment, there’s something fundamentally wrong about that.”

    There was a dispute. Ms. Dunham tried to get disability insurance after she was diagnosed with cancer, apparently lied on the application form, but the truth was uncovered. There is no way Mr. Obama could have been ignorant of the facts as he acted as his Mother’s lawyer in the fight.

    But our President also stated that surgeons get reimbursed $50,000 to amputate a limb, when the actual figure paid by Medicare is between $740 and $1,140.

    These were just some of the lies and misinformation used to ram the ACA through. Conservatives were aware of these back in 2007 and 2008, and recent studies show that many Americans take most or everything the president says with a grain (or block) of salt.

    For all of the massive costs, heartaches, and lost coverage, to add so few “newly insured” patients looks to me like a disaster.

    1. Tia Will Post author

      TBD

      Your statement about the variability of death rates from this condition is true. I was quoting what was applicable to my daughter ‘s situation as quoted to us at the time of her admission as she was very ill.

      I am sure that people’s cost are extremely variable based on the stage of illness and how it needs to be treated.
      For example, if a patient needs extensive treatment in an ICU, the bills will be very much higher than if she does not. Also, some some people will need extensive time in psychiatric facilities. Total costs will also depend on the number of admissions needed. Since I never received any bills for this, the !50,000 dollar estimate per hospitalization was an estimate from her specialist who ball parked their usual admission costs for me for a months stay.

      I do not know how you think that an unemployable 22 year old ( due to illness, not ability or skills) is going to either be able to pay for her own health care of get an individual insurance policy, let alone for a “song” 2 months after graduation which is when she was diagnosed. This can now be accomplished through the ACA since her insurance could be subsidized and the the “pre existing condition ” clause does not apply any longer. What we heard from other people whose insurance was not nearly as good as mine or his daughters had not had insurance were stories of houses being sold and savings accounts drained to keep their daughters alive. Since these people were not publishing their stories, I am sure they had no reason to lie.

      As for exaggerations, I am quite sure that they have existed on both sides of this debate. What I have presented is just one practitioner’s view based on 30 years of first hand experience with the discrepancy of care people received under the previous fee for service model of care. I would prefer to absorb the cost, have temporary inconvenience as people re enroll in new, and sometimes better plans and have those who were not able to access care previously now covered. I also do not share your view that this is “so few”, and it seems to have been steadily climbing.

      1. TrueBlueDevil

        Tia, even a few years ago I saw very inexpensive rates for buying health insurance coverage on the free market as a single individual, if one was young. Young people are generally healthy. If I recall, rates rise in our 30s, 40s, and then really begin to spike in the 50s. I’m unsure if your daughter was covered by your plan, and don’t need to know, but as a young adult she could have purchased her health insurance for a relatively cheap rate before she became ill. I understand hindsight is 20 / 20. I recall seeing rates for Blue Cross and others that were $45 per month, or less.

        I think sometimes these discussions get blown out of proportion and reality. I recall during the ACA debate a woman calling a local radio show, and she said that her husband had beaten cancer and was in remission. But she felt it was unfair and burdensome that their health care coverage premium cost maybe $550 per month. As I thought about it, from 1990 and before the type of cancer her husband had was usually fatal, and for the price of what many people pay for a car payment, she has a healthy, cancer-free husband.

        1. Tia Will Post author

          TBD

          ” even a few years ago I saw very inexpensive rates for buying health insurance coverage on the free market as a single individual,”

          And can you tell me just exactly what these plans covered ? And can you assure me that they would not have been denied for a mistake as simple as not putting down on your application that you had been treated for acne. If you think that never happened, or is an exaggeration, I can assure you that it was not.
          My brush with mononucleosis in my teens would have prevented me from purchasing some of those wonderful, inexpensive plans you are citing.
          It has not been unusual in my experience to hear directly that a woman’s insurance
          that she had paid into faithfully for years was cancelled on a technicality once a big ticket diagnosis was made.

          If these insurance companies had not been bait and switching customers for years, I would agree that “low cost plans” were great. Unfortunately too often you got what you paid for. If there had been no problem, there would have been no need for a change regardless of whether or not you like the one we got.

    2. D.D.

      If my daughter had anorexia and the rate was 5% or even one half of one percent, I can assure you I’d do everything in my power to make sure she was not in that 5%.
      The sad reality is that in America, we have the money to treat people.
      Last night’s episode of 60 Minutes should reinforce that. The billionaires on 60 Minutes who are trying to make a real social/humanitarian difference with their billions – those folks – are an inspiration. Their accumulated wealth is more than 50% of all the people in America’s wealth combined, I think.

          1. Frankly

            They get a lot of it taken away in death tax and it goes to the government that then redistributes it to others.

            And don’t forget all the charitable stuff they do.

            A lot of people discount that and point to the gross income. Bill Gates is worth $50 billion, but most of his wealth was put into the Gates Foundation. But those that want to keep waging class war just point to the $50 billion and cry that it is not fair.

          2. TrueBlueDevil

            So what’ the problem? They earned it with their BST (blood, sweat, and tears), their education, their risk taking, their delayed gratification. They provided a value or service that others valued highly.

            On top of that, they pay various taxes at numerous levels. They employ hundreds or thousands of people. And when they save or invest money, it helps build American business.

            Would you rather they be on welfare or working at Walmart, and their employees go on the welfare rolls, as well?

  23. WesC

    Here is a pre-ACA case that I am personally aware of. The young man had a congenital problem with his liver which caused it to deteriorate over time. He and his brother owned a small construction company which they inherited from their father. Because their insurance policy would not cover his pre-existing liver problem they ended up selling off equipment to pay for his care. Knowing that it would bankrupt the company , he sold his half to his brother for a token payment and went on Medicaid. When he reached his mid 20’s he got to the point of needing a liver transplant, which he received and did very well. He felt bad about being on Medicad and searched around for private health insurance. The only insurance company that would sell him a policy wanted $1,000/month in premiums for him alone (which he said he was willing to pay), wanted 18 months premiums before the policy would kick in, and would not cover anything related to his pre-existing condition which was his liver transplant. He took Prednisone, Imuran, and Cyclosporin at the time to prevent organ rejection which were costing over $1,000/month.. Some of the significant side effects of these meds are brittle bones, immunosuppression, renal disease, cancer, diabetes, and others. So the policy would not cover fractures (brittle bones from prednisone!), infections (immunosuppressed from all 3 drugs), any renal problems, cancer, diabetes, and just about everything else that could happen to a person. He said he had no choice but to intentionally stay poor to get Medicaid. These are all 1990 prices.

    1. TrueBlueDevil

      This was a problem area that needed to be addressed.

      We could have created a high-risk pool, supplemented the cost, and done other things, without blowing up half the system in a failed attempt to expand coverage to 20-25 million (which they claimed was 40-50 million).

      1. Don Shor

        We could have created a high-risk pool

        Ah, yes. The ‘high-risk pool’ solution. Put us in our own special insurance ghetto, with unsustainable costs, so the insurance companies can shunt as many “high-risk” (by their definition) customers out of their pool. Here’s a good discussion: http://theincidentaleconomist.com/wordpress/the-trouble-with-high-risk-pools-as-a-conservative-alternative/
        Expanding the risk pool by including everybody — i.e., the individual mandate — is a much better solution.

        1. Don Shor

          Let me give you just one example from the comments section of that link I provided so you see why “high-risk pools” are completely unsustainable, result in adverse selection, and would require constant Congressionally-authorized increases in funding:

          A typical example is Multiple Sclerosis. There are no known lifestyle risks for the condition so there isn’t any moral hazard to covering it. It causes gradual paralysis but it doesn’t kill. This process of paralysis can be slowed or even halted with treatment allowing people to live a normal life, but that treatment is very expensive. …
          If they are diagnosed at 32 and live to be 62 (not at all unlikely) and are taking Rebif, they will cost the insurance company 12 months x 4000$ x 30 years = 1,440,000 dollars. No insurance company wants to touch that, this isn’t a risk, it’s a guaranteed money sink. If health insurance was just like car or home insurance, an MS patient would be committing fraud everytime they tried to get insurance.
          But the subject was high risk pools. There are 400,000 MS patients in the country, let’s say half of them are on treatment so 200,000. Let’s say they take their drugs and pay a 600$ copay per month (what medicare patients pay for MS drugs now). How much would it cost to put these people in a high risk pool for a year?
          That’s 200,000 people x 12 months x (4000 dollars – 600 copay) = 8,160,000,000. That’s 8 billion dollars for one chronic disease for one year.
          So in conclusion, there are a lot more people who need high risk pools than you think, and it would be vastly more expensive than you seem to believe.

          1. D.D.

            Dear Don,
            Thank you so much for clearly explaining my friend’s plight. The day her teenaged daughter told her mom her leg “kept falling asleep”, while she watched t.v. over high school spring break, was a turning point in that family’s lives. Like I mentioned earlier, even with their health insurance, with the co-pays, they would have lost their home if it was not for the ACA. Their son also has an illness.

          1. TrueBlueDevil

            Don, you give less than half the story. Many of the young applicants are like Tia’s daughter – they signed up on the family plan. Costs will rise more than expected nest year due to this factor.

            Forbes: “Overall, the Federal government reports that 32% of on-exchange enrollees as of March 1st are under the age of 34. And many of these are teenagers who are part of family policies, not the young yuppies that Obamacare is fervently targeting. Earlier estimates showed only 20% of enrollees were between the ages 18 and 34.

            “The final number of young enrollees is well below the required cohort. Premiums will rise next year as a result of the adverse selection of older, and probably less healthy consumers. Why are young adults staying away? In one word, economics.”

            “Obamacare is asking young adults to effectively subsidize the healthcare costs of older Americans. So far, Millennials are resisting this age-based transfer of wealth. Many are clearly opting instead to remain uninsured, or else they are buying cheaper health plans that don’t conform to Obamacare’s regulatory dictates.”

            “Look at our numbers (laid out in the charts below) and you’ll see why so many Millennials have Obamacare sticker shock. Someone, for example, earning $25K annually in Arizona will pay $2,424 in total monthly premiums for Obamacare (10% of their annual income) and still be stuck with a $4,000 deductible and a $5,200 cap on their out of pocket costs….”

            http://www.forbes.com/sites/scottgottlieb/2014/03/28/how-much-does-obamacare-rip-off-generation-x-we-ran-the-numbers-here-are-the-results/

            That’s a $200 a monthly premium for a young person making only $25,000 per year!

          2. Don Shor

            Gottlieb’s analysis that you cite has numerous flaws, most of which are fully described in the comments to the article itself. Just curious: do you actually think a health premium that is 10% of income is expensive? Do you really think most young buyers are opting for the Silver plans? And how do you think all of this compares to what the person would have paid pre-ACA?

          3. TrueBlueDevil

            If you’re a “young invincible”, as they call them, why do they need to spend $150 or $200 per month of health care coverage (to cover granny)?

            In a perverse twist, the ACA is too cute, too clever. Because these young people can choose to not be covered and pay a nominal fine; and then if they come down with cancer or get ht by a car, they can sign up, as pre-existing conditions are covered.

            There was also a huge propaganda campaign that turned off a lot of young people.

          4. Don Shor

            Because these young people can choose to not be covered and pay a nominal fine; and then if they come down with cancer or get ht by a car, they can sign up, as pre-existing conditions are covered.

            Yes, and you know what was really “cute” before ACA? As soon as they got sick, they couldn’t get insurance. Or they couldn’t get insurance that covered the thing they were sick with. Or they could get thrown off of a plan for almost any little thing.
            That was really “cute.”

          5. Frankly

            Yes, and you know what was really “cute” before ACA? As soon as they got sick, they couldn’t get insurance. Or they couldn’t get insurance that covered the thing they were sick with. Or they could get thrown off of a plan for almost any little thing.
            That was really “cute.”

            Please stop using that as your disingenuous fall back defense to justify Obamacare. Everyone agreed that pre-existing conditions needed to be dealt with. There were alternative proposals that would have dealt with it. We did not need Obamacare in all its destructive force just to deal with per-existing conditions.

          6. Don Shor

            Everyone agreed that pre-existing conditions needed to be dealt with. There were alternative proposals that would have dealt with it.

            Nope. But I’ve answered this assertion before. Obviously no point in repeating myself.

    2. DavisBurns

      Yes, the joys of staying poor to remain on Medicaid! You are allowed to own a car and a house and those don’t count toward your assets but you are allowed to have a total of $2000 in assets. I think this number was last raised in the early 70’s. This means if you have $1250 in the bank and receive a check for $800 you have assets of $2050 and when audited, you will no longer be eligible for Medi-cal. For the working poor, ACA has allowed them to have coverage and pay a premium but for the fixed income crowd, the rules are draconian.

  24. Tia Will Post author

    TBD and Don

    Of interest to me about your last exchange is that it for me points out the heart of the matter. TBD, you seem to believe that the free market, if left to its own devices would have taken care of its own problems. Don, you and I seem to share the belief that if the free market was going to deal with these problems posed by the inadequacies of our previous “system” it had plenty of years in which to do so and that since this had not occurred,
    government intervention was necessary.

    The bottom line for me is not that I love Obamacare. It is that the “system” we had did not just have one or two problems as
    Frankly maintains, it had many, and despite what ideas may have been floated on either side, until Obamacare, nothing had been done. That it the reality. So if you are on the right and you hate Obamacare, look in the mirror with regard to why your side didn’t take the steps that you say would have fixed the problem.
    If you are further on the left, do the same.

    We got Obamacare ( either “shoved down our throats” or “rightfully enacted” depending on your point of view) because the leaders we have elected failed repeatedly to provide anything else that would pass electorally and judicially.

    This is what we got by our competitive, winner take all system.
    Imagine what we might have had if both sides had been truly willing to sit down and collaborate with all sides at the table from the beginning.

    Frankly is found of saying “Lead, follow, or get out of the way”. We have a law which has passed as Don stated both legislatively and judicially. Is it not time for those who did not get exactly what they wanted on either side to head Frankly’s advice?

  25. TrueBlueDevil

    Tia, I agree, but put the onus elsewhere. Congress failed to provide leadership or incentives, so we’ve exchanged a number of problems – which were fixable – for a government Goliath. Waits to see a doctor can top 6 months in England, and than doesn’t even comment on the quality of service.

    Look at the VA system, that should be quite illustrative of how government operates compared to the private sector.

    I realize that people on the left think that government is the solution, while those on the right think it is a solution of last resorts. Look at gov’t housing (projects) compared to private housing.

    If ObamaCare is so great, why did the President, Congress, and their staffers exempt themselves from the system? Hypocrisy?

    Actually, what our system also got us was a system where we had two previous White House candidates vying to see who could give more low-cost or no-cost drugs to seniors, without paying for it, essentially using our children’s money to buy their votes. Which added trillions more in debt.

    Tia, mammoth, fundamental lies were repeatedly told by President Barack Obama and his ilk to get this legislation shoved through in the middle of the night. This was not Social Security or Medicare, which were passed with bipartisan support.

    1. Don Shor

      for a government Goliath.

      Private insurance to see private doctors, purchased through a public exchange. That’s not exactly a “government Goliath.”

      1. Frankly

        How many total government employees had to be hired, and will need to be hired, to administer Obamacare?

        The number of such workers, obtained through documents and interviews with officials, consultants and contractors, could be significant enough to produce a modest, if temporary, boost to employment across several industries.

        But the precise size of this workforce is shrouded in secrecy. The Department of Health and Human Services (HHS) did not reply to a question asking how many people it has hired or assigned to implement healthcare reform, and companies with government contracts worth tens of millions of dollars are similarly tight-lipped.

        The good news is that the number of federal and state employees hired to handle Obamacare has helped Obama and the Dems improve their unemployment numbers from terrible to a little less than terrible.

        And ironically…

        A new survey of 2,500 federal employees and retirees found that 92.3 percent believe federal workers should keep their current health insurance and not be forced into ObamaCare. Only 2.9 percent say they should become part of the new health insurance exchanges.

      1. TrueBlueDevil

        Obama the Wonderful was warned twice about this problem when entering the White House, In their pompous, arrogant way, they blew it off.

        It appears to me that Obama spent more time giving speeches, watching basketball, going to concerts, attending fundraisers, watching ESPN, smoking, and playing golf… than he did trying to fix the VA. Either that, or he is utterly incompetent. Take your pick. Maybe both?

    2. Tia Will Post author

      TBD

      “Waits to see a doctor can top 6 months in England, and than doesn’t even comment on the quality of service.”

      Why don’t we wait to see what happens to wait times here instead of assuming that we will have wait times comparable to England.

      What I have seen here In my office in Davis is that the new patients coming to see me are able to get appointments within one week consistently and frequently on the same day. If there is a gyn referral from a medicine, family practice or pediatric doctor in Davis, we will always see the patient the same day if the patient has time. That is because we have a policy of maintaining a surplus of appointments. If the demand becomes too great and my backlog is building I open more appointment time. Now with the increases we have seen from the ACA, we are going to be hiring more doctors to meet the demand. With these new doctors will come new positions for nurses, medical assistants, office support, surgical assistants, IT support, building maintenance workers….. If one is of the belief that market activity that leads to more jobs is good, then at least as far as the Kaiser experience in Northern California goes, the ACA has been a greater driver of economic opportunity. This was only with the first year. We are anticipating further growth next year. So even more economic opportunities in many fields.

      1. D.D.

        Tia, I really respect your opinions and want to say this comment about Kaiser in a nice way. When I selected Kaiser for a coupe of years, my experience with the mental health doctors, pharmacy, and pediatrics was stellar. (the mid 1990’s).
        The other doctors, it seemed like it was a cattle call. Big and impersonal. Many of the services I needed were referred to Vacaville, which was not convenient. So I went back to another carrier.

        I had similar complaints from my workers comp claimants, when I was a claims adjuster. That was a little ironic, since Kaiser used to lead the way in workers’ comp health care.
        I have not spoken to anyone in Davis in the last few years who uses Kaiser, so perhaps all these comments are wrong now.
        I sincerely hope that as Kaiser grows, they can somehow personalize their service. Maybe it is just the bldg. It seems so big and sterile, compared with a small doctor’s office. Maybe it’s the way all the patients line up. If you “snaked” the lines like they do at Disneyland, people aren’t facing someone’s back while they wait in line. More live plants would also give the surroundings less of a government feel.
        My sister is in her open enrolllment period. She asked me my opinion of Kaiser, and I told her I don’t have any current experience, but I told her about my past experiences. She’s still making up her mind. (She lives in the bay area, so I have no clue about the Kaiser doctors over there.)
        What I love about Kaiser is that the doctors and many of the staff do not have to stress about ICD 9 codes and fee schedules and collection issues. They can focus on wellness.

    3. Tia Will Post author

      TBD

      One thing that you do not seem to be appreciating is that Obamacare is not “running the health care system” in the sense that the VA is government run.

      My practice is part of the Permanente Medical Group. We are a private company, not government run. There is no one, not the government, not an insurance company, not any kind of review board telling me how to practice medicine. The decisions that are made in my office are made between the patient and myself, period. I do not have to ask permission of the government, of an insurance company, of any regulatory agency to decide how best to treatment my patients and I do not incur any financial advantage or penalty for suggesting one form of therapy over another. I am seeing many new patients who are able to have the advantages of this type of system for the first time through the exchanges. I see this as an enormous good. Perhaps you would disagree.

      Again, as with any very complicated system, Obamacare has it’s strengths and doubtless has weaknesses.
      It would not have been my preferred option.
      So far, from my point of view, the benefits out weigh the disadvantages, but then I have a front row seat, I am not solely getting my information from which every news media ( right or left) I choose for my information.
      I am directly hearing the stories of my patients which now, like throughout my entire career, have shaped my view of health care in our area.

      1. TrueBlueDevil

        I am trying to keep an open mind… it is a complex system, and new information seems to come our weekly, or daily. Yes, I have two acquaintances with pre-existing conditions who are happy. They’ve also chosen to be unemployed at times (both college degrees from the UC, marketable skills), and like how this has filled the gap.

        I can say that the rollout of the ACA website was a disaster that may foretell the future of the ACA. At the same time, three hi-tech workers put out a far cleaner web front end … in one weekend! (It doesn’t connect to the multiple backend databases.) This is a perfect analogy of how the free market runs circles around the government.

        https://www.healthsherpa.com/

  26. Tia Will Post author

    TBD

    “I can say that the rollout of the ACA website was a disaster that may foretell the future of the ACA”

    I smile every time I hear someone say that the rollout of the ACA was a disaster. I think we must have very different views of what constitutes “disaster”.

    From a doctor’s point of view, disaster is the patient who dies early of preventable or treatable illness. Or the family that loses their home because someone’s illness and subsequent loss of job means that they cannot keep up with the mortgage payments. On a societal level it is a natural disaster such as Katrina, or a man made disaster such as 9/11.

    The rollout of the ACA website was a poorly executed glitch which should not have occurred. It was not a disaster.
    No one died because of a poorly executed web site.
    What people who would prefer not to see any good in the ACA keep bringing up are peripheral issues or completely unrelated issues:
    1. )The web site
    2. “He lied to us” …..like this is the first time that that has ever happened with a president, even if you interpret
    his statements that way ( anyone remember other “lies” that have costs thousands of lives)
    3. Death panels
    4. The VA – as though that had anything at all to do with the ACA

    What I would encourage people to do is to give this a little time. What we had previously was, for those who did not have either very good employment or government provided health care, quite literally a “disaster” if they developed a significant illness that their insurance would not cover or if they lost their job. Instead of spending vast amounts of time, energy and money attempting to repeal this law, imagine where we might be had those legislators come forth collaboratively to improve the “glitches” both large and small.

    I do find it encouraging that you are trying to keep an open mind TBD.

    1. TrueBlueDevil

      I recall these discussions about the costs of health care in college decades ago. I recall the professors coldly saying we could pay $50,000 to extend the life of an elderly person 6 months, or vaccinate 5,000 children, which is then $10 a child.

      1. If you actually do the calculus, these enormous costs have consequences. As of this December the ACA website has gone over $1 Billion in costs; and all of the ACA websites combined have topped $5 Billion. Many don’t work, and the ACA website has huge numbers that don’t match up with the information provided on other, related databases… which haven’t been checked. Private IT contractors are on the record saying they would be embarrassed to accept anything more than $10 Million for such a project, and some critical IT decisions may have driven these costs due to political considerations.

      I think this example, and how you brush it off, is illustrative about how some have no concern or care about fiscal matters and efficiency. And at the end of the day, it is our children and grandchildren who will bear the massive costs. I guess I shouldn’t be surprised as Obama is on the way to racking up $10 Trillion in new debt added to our national credit card. (George Bush Jr. was no tightwad.)

      http://www.usdebtclock.org/

      2. I don’t recall our Presidents telling fundamental lies about Social Security or Medicare, but I gather Mr. Obama may have used Sal Alinsky tactics here. If he didn’t lie about losing our doctor and health plans, it wouldn’t have passed.

      I think it was also Tip O’Neil and other Democratic icons who said that you need 60 or 65 votes for major legislation, so that it would stand the test of time. Bi-partisan. Another item BO considered irrelevant.

      3. “ObamaCare’s cost-cutting board — memorably called a “death panel” by Sarah Palin — is facing growing opposition from Democrats who say it will harm people on Medicare.

      “Former Democratic National Committee Chairman Howard Dean drew attention to the board designed to limit Medicare cost growth when he called for its repeal in an op-ed late last month….”

      “…Major healthcare interests like the American Medical Association, the American Hospital Association and the pharmaceutical lobby have supported IPAB repeal, saying the panel would cut providers’ pay arbitrarily.”

      Read more: http://thehill.com/policy/healthcare/316045-obamacare-cost-cutting-board-faces-growing-opposition-from-democrats#ixzz38J565PI4

      4. The VA is further illustrative of how the government can’t run health care properly.

  27. Tia Will Post author

    TBD

    That’s a nice site. It would have saved people some time and frustration. What it would not have done is to have saved anyone’s life. The ACA has already done that for a number ( or at least dramatically lessened their chances of dying from advancing untreated disease) of people that I have witnessed personally because of my job.

    It is very hard not to like a program when every day you meet people who are truly in need of care and now have the opportunity to get it for the first time in years. I admit that this is my bias because of my career. In my eyes,
    anything that strengthens the health of individuals and our community is a positive. If that also happens to provide more jobs ( yes in both the public and private sectors) then that also is a positive. As a doctor, I am very focused on the health effects of the program, not the very messy way it came to be passed , affirmed and implemented.

  28. TrueBlueDevil

    But Tia, how about the people who have lost coverage, lost their health care, lost their doctor or specialist? Dr. Tom Coburn, in Congress, lost his cancer specialist!

    Here is an interesting article to ponder.

    Forbes: How Obamacare Will Harm Cancer Patients

    “Obamacare is going to degrade medicine but its ill effects will fall disproportionately on patients with serious conditions, especially those diagnosed with cancer.

    “The legislation contains provisions that directly target patients with cancer because their care is perceived as costly. These policies couldn’t be more badly timed….”

    http://www.forbes.com/sites/scottgottlieb/2013/08/21/how-obamacare-will-harm-cancer-patients/

    1. Matt Williams

      TBD, here’s an interesting article for you
      http://www.huffingtonpost.com/2014/07/23/obamacare-insurance-uninsured-rate_n_5615052.html It begins as follows:

      “The number of Americans without health insurance declined by 10.3 million because of Obamacare enrollment, according to a report from the Department of Health and Human Services and the Harvard School of Public Health, published in The New England Journal of Medicine on Wednesday.”

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